Learnings From Bihar-Childhood Diarrhoea Management ... · Learnings From Bihar-Childhood Diarrhoea...
Transcript of Learnings From Bihar-Childhood Diarrhoea Management ... · Learnings From Bihar-Childhood Diarrhoea...
Issue No. 10
Learnings From Bihar-Childhood Diarrhoea Management Program In Chhattisgarh
ince 2009, MI has been working in Bihar and Chhattisgarh
through public health projects to promote Zinc and ORS for
childhood diarrhoea management. In Bihar, MI started the
program in 15 demonstration districts, and later as
evidence of impact grew, the state government scaled-up the
operations to all districts. In the 15 MI demonstration
districts, nearly 2 million
cases of childhood diarrhoea
have been reported treated
between August 2011 and
February 2015; of which
70 percent have been treated
using both Zinc and ORS.
A p a r t f r o m i m p r o v e d
coverage of Zinc and ORS,
MI's project in Bihar has
d e l i ve re d e n co u ra g i n g
results on sustained levels of
knowledge of frontl ine
health workers, improved
and detailed reporting on
childhood diarrhoea cases by
health workers, project and
HMIS (Health Management
Information System) reporting,
streamlining of Zinc and ORS supply chains, and generating
awareness among key stakeholders. As this project funded
by the Children's Investment Fund Foundation (CIFF),
culminates in Bihar and steadily become sustainable, MI
draws upon the key lessons and forges new ties with the
Chhattisgarh government with the support of CIFF. Starting
April 2015, MI in Chhattisgarh, has initiated a project to
support in strengthening the state's program on childhood
diarrhoea management, while promoting continued feeding
during and after illness. Some of the other key components
of the project are; training of frontline health workers at the
state and district levels on Childhood Diarrhoea
Management using Zinc and ORS, and improved reporting
and treatment of diarrhoea cases.
T h e U n d e r - F i v e
M o r t a l i t y R a t e o f
children in Chhattisgarh
is 55, which is higher
t h a n t h e n a t i o n a l
average of 52 (Per 1000 1live births). Of all
under-five deaths in
India, 11 percent can be
a t t r i b u t e d t o 2d i a r r h o e a . P u b l i c
sector care-seeking for 3diarrhoea is 31.7% in
Chhattisgarh among
children (0-2 years age
group), and the rate of
O RS u s a ge a m o n g
children in this age
group is fairly high at
61.5%. There is thus significant potential for larger number
of children to be treated with the recommended combined
therapy of Zinc and ORS, provided supplies are smooth and
the health system has the capacity to deliver.
MI has achieved much impact in Chhattisgarh, through
previous child health interventions supporting the
Government. High-level discussions with government
Learnings from Bihar – Childhood Diarrhoea Management Program in ChhattisgarhImproved supplies of Zinc & ORS in the Public Health System Innovative Links in the Supply Chain Pilot - Enhancing Access to Zinc & ORS Program Champions - Institutionalizing Supportive Supervision of Frontline Health Workers
1 Millennium Development Goals India Country Report 2014, Social Statistics Division, Ministry of Statistics and Programme Implementation, Government of India.2 WHO 2012 estimates.3 Coverage Evaluation Survey 2009.
Zinc with ORS in helping children recover from diarrhoea faster, resist thedisease longer, and have fewer episodes each year.
S
Aug-11
Oct-1
1Dec-
11Fe
b-12
Apr-12
Jun-1
2
Dec-12
Aug-12
Oct-1
2
Feb-1
3Apr-1
3Ju
n-13
Aug-13
Oct-1
3Dec-
13Fe
b-14
Apr-14
Jun-1
4Aug-
14Oct
-14
Feb-1
5
23
44 1
03
64
13
88
2
19
93
3
40
28
84
16
41
37
45
83
88
20
34
47
93
68
70
11
97
9
70
86
19
14
21
72
77
25
93
42
49
10
18
54
3
23
22
92
04
37
27
07
12
54
40
31
28
92
79
99
31
55
22
93
61
34
13
3
41
70
24
30
13
37
79
93
88
28
41
80
54
36
13
48
12
45
30
55
58
02
36
80
79
65
85
67
56
50
62
89
67
00
79
54
64
66
11
49
65
57
87
67
19
63
34
97
33
75
78
13
66
68
54
62
75
07
31
52
79
52
56
72
10
71
73
7
55
20
76
72
83
64
04
74
53
59 5
57
63
81
18
45
82
42
61
36
63
95
27
27
89
21
65
54
24
90
71
13
05
10
97
43
65
07
74
7
32
63
9
46
10
46
66
53
52
3
30
93
74
27
45
14
45
60
52
70
64
25
8
53
28
2
50
15
9
40
09
4
40
02
3
35
15
2
Dec-14
48
27
36
81
7
espite efforts by the Bihar government to improve
procurement in the public health sector, stock-outs of
essential medicines like Zinc and ORS are not uncommon.
Other supply-side challenges for Zinc and ORS, are the
procurement tenders lacking detailed product specifications,
procurement of low-price but sub-optimal formulations, and
the sporadic availability of Zinc and ORS with frontline health
workers at the village-level.
To tackle this gap situation, and in response to the follow-up
efforts of MI, RMNCH+A partners and Government of India,
the Bihar state government tracked stocks of 10.3 million
Zinc tablets (deemed sufficient for at least 735,714 cases of
childhood diarrhoea), available with the Bihar Medical
Services & Infrastructure Corporation Limited (BMSICL) and
alongwith 1.47 million packets of ORS, drew up a plan in
January 2015, for a swift dispatch. In February, all districts of
Bihar had reportedly received Zinc and ORS supplies, with
stocks soon reaching all PHCs and sub-centers.
To ensure supplies in forthcoming months as well, MI has
supported the state government to issue a new tender for
the procurement of Zinc, by providing details on product
specifications to BMSICL (Health Department, Government
of Bihar) and advocating for its e-tendering.
There is a gradual but certain improvement in the availability
of Zinc and ORS in Bihar. This is reflected in the number of
childhood diarrhoea cases being reported treated in the
public health sector, using Zinc and ORS. So far, between
August 2011 and February 2015, in the 15 demonstration
districts of MI, in the public health sector 2 million cases have
been treated with both Zinc and ORS.
Ensuring access to Zinc and ORS is key for managing childhood diarrhoea.
Improved Supplies Of Zinc & ORS In The Public Health System
counterparts and representatives of the State Health
Systems Resource Centre have resulted in MI now
working to scale-up the use of Zinc and ORS in Chhattisgarh.
Some headway has already been made in this direction by
the state government, with programmatic and technical
support provided by MI. In the first quarter of 2015, the
Government of Chhattisgarh has procured 9.8 million Zinc
tablets (700,000 courses) through state funds, believed
adequate for about six months. For the year 2015-16 too,
MI has contributed its technical expertise to the state
government for making budget allocations for Zinc
and ORS procurement, which is reflected in the state's
Program Implementation Plan, under the National
Health Mission.
More than 2 million cases of childhood diarrhoea have been reported and treated at the public health sector in the 15 demonstration districts of MI, of which 70 % have been treated with both Zinc and ORS
D
Cases reported treated through project reportingCases reported treated with Both Zn & ORS (project reporting)
Innovative Links in the Supply Chain Pilot -
Enhancing Access to Zinc & ORS
he Government Of India guidelines mandate frontline
health workers like ASHAs, to manage childhood diarrhoea
cases using ORS and Zinc at community level. Yet irregular
supplies continue to impact access to this life-saving therapy.
In Bihar too, sporadic supplies in recent times, have impacted
the number of childhood diarrhoea cases being treated in
the public health facilities using Zinc and ORS.
MI's Childhood Diarrhoea Management Program
implemented with the support of Children's Investment
Fund Foundation (CIFF), is providing technical and
programmatic support to the state government. As part of its
project activities, MI is helping the government streamline
supplies of Zinc and ORS. MI is also providing technical
support through training of health workers, demand
forecasting, planning distribution, storage, monitoring and
reporting on stock status. This has brought out the crucial
role that Frontline Health Workers (FLWs) play in timely
provision of Zinc and ORS to the community.
In block Dumrikatsari of Sheohar, one of the districts lagging
behind in child health indicators, MI is currently
implementing an innovative supply chain pilot project, to
ensure timely supplies of Zinc and ORS to frontline health
workers. The innovation hinges on leveraging the existing
network of government healthcare personnel in the vaccine
delivery system. To ensure that Zinc and ORS reaches last
mile beneficiaries, MI is utilising the network of Courier +Service Men (CSM)*and Cold Chain Handlers working in the
government's Vaccine Delivery System in Bihar.
As part of the pilot, CSMs are entrusted with carrying a
'Supply Chain Replenishment Kit' alongwith vaccines, during
their visit to the sub-center on the Village Health and
Nutrition Day. This kit contains adequate quantities of Zinc
and ORS for distributing to each frontline health worker as
per need. Upon reaching the VHND site, the CSM records the
Zinc and ORS stocks available with the frontline health
worker, assesses how much is needed, and accordingly
replenishes her stock with the supplies he is carrying. At the
day's end when CSMs return to the PHC, they hand over a
report on the Zinc and ORS stock status of FLWs to the Cold
Chain Handler. The Cold Chain Handler then sends forth a
compiled report, received from all CSMs, to the Medical-
Officer-In-Charge for his attention.
The innovation lies in assessing Zinc and ORS utilization rates
* - Courier Service Men transport vaccines to the sites on a pre-decided Village Health and Nutrition Day .
+ - Cold Chain Handlers are health personnel i.e pharmacists, multi-purpose health workers etc who are tasked with proper storage and handling of vaccines, daily upkeep of refrigerators and temperature charting.
and immediate replenishment of stocks with frontline health
workers in real-time. Otherwise, in the public health system,
frontline health workers receive only one-time supplies of
Zinc and ORS in the year from their respective PHCs, and
there is no mechanism of regular replenishment or stock-
taking once their stocks finish, leading to possible gaps in
treatment of childhood diarrhoea. Going a step further now,
with MI's support, the CSMs have been trained to send a
coded SMS on the real-time stock status of Zinc and ORS with
the FLW. Data from these SMSs gets entered onto the online
data entry package. Some of the challenges this innovation
seeks to overcome, stem from the semi-literate status of
CSMs, giving rise to difficulty in data capturing, and other
challanges pertaining to mobile network availability.
Timely treatment with Zinc and ORS can save millions from childhood diarrhoea, empowering the generations to come.
T
Program Champions - Institutionalizing Supportive Supervision Of Frontline Health Workers
key component of the support provided by MI to the
Bihar government under the Childhood Diarrhoea
Management Programme, has been Supportive Supervision
of Frontline Health Workers in 10 districts. Herein Block
Community Mobilizers (BCMs) working under the State
Health Society (Govt. of Bihar) were trained by MI to provide
on-the-job training and hand-holding support to frontline
health functionaries (ANMs, ASHAs, AWWs) during their
visits on Village Health and Nutrition Days. This helped
the frontline health workers tackle field-level challenges
while dealing with childhood diarrhoea-related cases.
During the BCMs visits, an ANM, atleast one ASHA and one
AWW under the purview of a BCM were supervised. Further
the BCM visited two caregivers serviced by this ANM and one
caregiver each serviced by the ASHA and AWW. A BCM from
block Salkhua, who had earlier attended a state-level
training on Supportive Supervision facilitated by MI says,
“Now I can better empathize with ASHAs and ANMs and the
challenges they face in the field. It has helped me connect
with them more effectively”. In the three years of supportive
supervision, nearly 22,000 frontline functionaries have been
visited by BCMs, to fill capacity gaps and address service
delivery issues in childhood diarrhoea management using
Zinc and ORS. As a result, the data on supportive supervision
reflects that knowledge levels of frontline health workers on
childhood diarrhoea management, have remained
consistent.
As MI's Childhood Diarrhoea Management Program in Bihar
steadily becomes sustainable, a systematic process
evaluation of the Supportive Supervision component has
revealed that Supportive Supervision has indeed
contributed to improving frontline healthcare worker's
motivation levels, especially in context of their knowledge
on Zinc and ORS for managing childhood diarrhoea, their
counselling skills, helping them meet job expectations
and gain social recognition as skilled medical service
providers. “Our efficiency at work improves as we are
provided with a lot of information and good advice by the
BCMs. This helps us improve at our work”, says an ASHA in
district Madhepura.
Now that the project is gradually becoming sustainable, MI is
working with the Bihar government to ensure that
supportive supervision of frontline health workers continues
as a part of the BCMs routine supportive supervision and
community visit tasks.
A BCM (Right) in Sultanganj village (Bhagalpur district) observes an ASHA as she prepares the ORS solution at a caregivers' home.
A